2011 MEMBERSHIP FORM

January 1st through December 31st, 2011

Dear fellow Druze,

Now is the time to renew your ADS membership!

You will receive many benefits from your ADS membership, including but not limited to:

- Discount on Local & National ADS events

- Voting privileges for Local & National elections

- Quarterly subscription to “Our heritage” Magazine and
   local chapter publications,

- Official ADS Membership card,

- The satisfaction of contributing to your society!!!

In order to fully capitalize on the benefits of becoming an
official member of the American Druze Society, your
membership dues must be paid to your local chapter or the National Office by March 31st, 2011.
Anyone who becomes a member after March 31st, 2011,
will not be eligible to participate in any Local or
National elections for the 2011 calendar year.

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Please complete the form below and submit it along with your
payment to your local chapter. Membership rates are as follows:

___ Lifetime Member & Spouse $1,500.00

___ Lifetime Member $1,000.00

___ Husband & Wife $90.00

___ Individual (17 yrs. & older & not a student) $50.00

___ Individual (17 yrs. & older & attending school) $40.00

___ Friend of the society (*discounts only, no voting privileges) $35.00

Member’s Name: ______________________________________
Spouse’s Name: __________________________________

Name (as will appear on membership card):
___________________________________________________________________
Children’s names & ages:

1) ____________________ ___ years old
2) ____________________ ___ years old
3) ____________________ ___ years old

4) ____________________ ___ years old
5) ____________________ ___ years old
6) ____________________ ___ years old

Address: ____________________________________________________________
Phone: _________________________

Mobile: _____________________________
E-mail address: __________________________________________________

Method of payment (Please select one): ___ CASH ___ CHECK ___ CREDIT CARD

Credit Card #: _____________________________
Cardholder’s name: ____________________________________________________________

Card: ___ VISA ___ MC ___ AMEX Exp. Date: ____/____ Security Code: ______
Credit Card Authorized Signature: _______________________

Billing Address: _____________________________________________________
City: _________________________ ST: _____ Zip: __________

I authorized the American Druze Society to charge $___________ on my credit card,
and I understand that I am fully responsible for the stated amount.

Check #: ______________ Bank: _____________________________________
Amount: ______________________Signature: ___________________________